Authors

Mitch Keamy is an anesthesiologist in Las Vegas Nevada
Andy Kofke is a Professor of Neuro-anesthesiology and Critical Care at the University of Pennslvania
Mike O'Connor is Professor of Anesthesiology and Critical Care at the University of Chicago
Rob Dean is a cardiac anesthesiologist in Grand Rapids Michigan, with extensive experience in O.R. administration.

Big Brother: Coming Soon to a Hospital Near You!

A prevailing belief in the modern world of health care is that outcomes
would be a lot better if people would just do what the best-evidence
dictates. In clinical practice, best evidence is incarnate in
guidelines and protocols generated by societies, associations, and
various empowered committees in hospitals and health care
organizations. Concerns about conflicting outcomes in the clinical
literature, the extension of the results from the study population to
patients in general, and whether the cost of the program is worth the
payoff are all safely classified as reactionary obstructionism by the
leaders of this revolution. Pay 4 Performance was sold as a way to
reward those who conform to ‘best practice.’ While it continues to have
advocates, sharp-end practitioners have collectively come to the
realization that P4P is a hoax intended to further reduce payments
(mostly government) to health care providers.

Where does all of this leave us? Well, at the highest levels, the
backers of best-practice believe that the problem is that we have not
gone far enough. Like the British generals prior to the Somme, their
belief is that success requires the same template executed on a larger
scale. In this instance, the belief is that practitioners routinely
ignore best practice, in spite of whatever the documentation they
generate might represent. Hence the only way to verify what happened is
to create an enduring, reviewable record.

While the vendor appears to be marketing comprehensive systematic
nearly prospective review; in reality such evaluations are certain to
be extraordinarily expensive. Worse, performing them on a large scale
would require an enormous number of hours, which would only be
affordable if the work was done by less-skilled reviewers, or exported
‘off-shore.’ Realistically, this record will be used to ‘look back’ and
determine the causes of bad outcomes. Do those who will be using this
system for this purpose possess the necessary expertise (e.g. training
as the NTSB would require)? I am unaware of any evidence to support
this assertion; in fact, I would be flabbergasted if this was the case.
Even in their infomercial, it is clear that they are focused on ‘Who
are the bad actors?’ rather than ‘Why aren’t these practitioners doing
what we want?’ This is not a trivial distinction; it is the difference
between mindless, punitive inspection and actually the kind of human
factors analysis necessary to improve performance (see The Inspections
Will Continue…..). Woe to the ‘bad practitioner,’ this technology
provides a mechanism to acquire evidence and levy sanctions.

Beware the briar patch. While many hospital administrators thirst for
information this detailed, most do not realize that it could consume
all of their time, and generate liability on a scale that they
previously have not encountered. Some observations for health care
organizations that are contemplating purchasing this technology:
1. If you don’t sanction practitioners for failure to comply, you’ll
have to justify that decision. If you apply sanctions appropriately, there
may be no one to do the work.
2. If practitioners comply with all applicable regulations and
guidelines, economic failure is certain in any but the most lucrative
practice environments. Nothing will get done.
3. Conflicting guidance will create organizational conflict. Where
guidelines conflict, practitioners will either act in accord with their
best judgment, or worse, compel institutions to generate guidance. This
technology requires the organization to have an opinion about
best-practice in every domain.
4. Legally, the enforcer assumes all of the risk. Plaintiff’s attorneys
will love this: it makes the hospital/clinic accountable for every
action of every practitioner. There will be no excuses for either not
knowing or not acting.
5. The ‘rules’ you enforce had better be defensible in the face of
litigation and continuously up-to-date. Every single one is likely to
be tested in the courts.

Of this I am certain: this technology will be a weapon to silence counter-revolutionaries and reactionaries.

Comments

I am reminded of the Buck Henry/ Gilda Radner skit of the 70s on SNL; the "Scotch Tape Boutique'" which was a sendup of ill conceived mall retail outlet schemes. If the market were not so pathetic, and if they were publicly traded I would short Arrowsight, since they obviously have no concept of the market. Hospitals all over are laying off QA workers, and here's a company looking for a casino-style manpower intensive security service. What are these people smoking? As Coolidge said, "If you see ten troubles coming down the road, you can be sure nine will run into the ditch before they reach you."